Neck masses Flashcards
Name 3 true emergencies involving a neck mass
Respiratory distress
Vascular compromise
Cervical spine cord compression
What components of the PEx are important for evaluating a child with a neck mass?
ABCs Level of consciousness Work of breathing Evaluate for stridor, hoarseness, dysphagia, and drooling Neuro exam
DDx for neck masses
CONGENITAL Hemangiomas Cystic hygromas Preauricular pits, sinuses, cysts Thyroglossal duct cysts Sternocleidomastoid mass Cervical ribs Brachial cleft abnormalities
INFECTIOUS
Lymphadenitis
Soft tissue abscess
Infected cysts (ie thyroglossal duct, brachial cleft, dermoid)
NEOPLASTIC Lymphomas Thyroid neoplasms Teratoma Rhabdomyosarcoma Neuroblastoma
TRAUMATIC
Subcutaneous emphysema
Hematoma
Cervical spine trauma
What are the anatomic classification of a neck mass and most common masses for each?
MIDLINE Thyroglossal duct cyst Lymphadenopathy Dermoid cyst Epidermoid cyst Parotitis Ectopic thyroid tissue
LATERAL Lymphadenopathy Cystic hygroma Branchial cleft cyst Sternocleidomastoid mass Sialadenitis Thyroid gland tumors
Define cystic hygroma
Malformation of the congenital failure of the lymphatic primordial buds to establish drainage into the venous system
Leads to the accumulation of lymphatic fluid and cyst formation
Discrete, soft, non-tender, mobile masses in the posterior triangle of the neck
80-90% appear by the end of the second year of life
10-20% at birth
What are the most common locations of cystic hygroma?
Near large veins and lymphatic ducts
Lateral neck (75%) Axilla (20%) Mediastinum (5%) Retroperitoneum (5%) Pelvis (5%) Groin (5%)
What is the most serious complication of a cystic hygroma?
Respiratory compromise and compression of the airway
Define thymic cyst
Due to faulty implantation of thymic tissue in the neck during embryologic descent into the chest
Midline masses
But can be present anywhere along the angle of the mandible and the midline of the neck
What is the most common head and neck congenital lesion identified in infancy
Hemangiomas
Usually after the 1st month of life
F>M
Soft, mobile, non-tender
Bluish or fiery red hue
Regressing hematomas are grey
Most common locations - face (lips, nose eyelids, ears), scalp
List some of the complications of hemangiomas
Hemorrhage Ulceration Infection Necrosis Thrombocytopenia and coagulopathies (due to platelet trapping, Kasabach-Merritt syndrome) Airway compromise CHF Visual impairment with some periorbital hemangiomas
Define branchial cleft cyst
Develop from malformations of the branchial arches (1st -4th)
Most commonly from the 2nd
Usually presents with a single painless cystic lesion deep to the anterior upper 1/3 sternocleidomastoid
Mobile, smooth, tense, and non-translucent and occasionally has clear mucoid drainage from a small opening
What are the most common complications of branchial cysts?
Infection
Tx with Abx, warm soaks
Definitive Tx - complete excision of the cyst and tract
Compare dermoid and epidermoid cysts
DERMOID CYSTS
Congenital
Inclusion of embryonic epidermis within embryonal fusion planes
Contents: lined by epithelium and contains sebaceous glands, hair follicles, connective tissues, and papillae
Location: Head and neck, lateral to supraorbital palpebral ridge, midline face, especially nasal bridge or neck
Can have intracranial extension (CT/MRI helpful to identify full extent of the lesion)
Tx: surgical excision
EPIDERMOID CYSTS
Traumatic or inflammatory
Follicular infundibulum of the hair shaft
Contents: Lined by epithelium, does not contain cutaneous appendages but rather keratinized debris
Location: Head and neck, lateral to the suprorbital palpebral ridge, midline face, especially nasal bridge
T: surgical excision
Describe a thyroglossal duct cyst
Common congenital neck mass
Due to a ductal ectodermal remnant that never obliterated
No external opening
Commonly found in kids 2-10 years
Midline cystic structure, immediately adjacent to the hyoid bone, at the level of the thyroid cartilage
3% sublingual
7% substernal
Soft, smooth, nontender
Moves when the child swallows or with tongue protrusion
CLINICAL DIAGNOSIS
What type of lymphadenopathy is concerning?
Supraclavicular - worry about malignancy (lymphoma)
What is the most common cause of acute cervical lymph node enlargement?
Infection
- Viral - most common (EBV, adenovirus)
- Bacterial (Staph, GAS, Strep pneumo, anaerobes, Barontella)
Presents with: URI Pharyngitis Tonsillitis Rapid enlargement of multiple adjacent nodes Marked redness, swelling and warmth Sometimes spontaneous drainage Can process to a retropharyngeal abscess Tx with PO Abx, unless toxic (IV Abx) If fluctuant - drain it
DDx of subacute or chronic cervical lymphadenitis
large, minimally tender, mildly inflamed, nonfluctuant node with no associated prodromal illness
Reactive response to a nonspecific infection (bacterial/viral) Cat scratch disease Infectious mononucleosis Mycobacterium tuberculosis (Typical or atypical) Toxoplasmosis CMV HIV Sarcoidosis Histoplasmosis Actinomycosis Malignancy
What is the workup for subacute or chronic cervical lymphadenitis
Complete Hx and PEx
Child’s overall general appearance
Assess the number, size and location of lymph nodes
Palpate for organomegaly
Labs - consider CBCD, EST, CXR, TB skin test
Abx to cover for Staph/Strep
Follow up/Disposition plan
Refer for biopsy if not responding to Abx therapy x 2 weeks and no other cause found
Describe the clinical picture of cat scratch disease
Unilateral tender node
Exposure to cat/kittens
Papule (scratch site) and lymphadenopathy usually develop 1-2 weeks after
Self-resolves in 6-8 weeks
Tx - warm compresses and analgesics
Abx - for severe local disease or systemic Sx
(Azithro, Septra)
How do you test for cat scratch disease
Bartonella henselae enzyme immunoassay (best initial test)
If negative –> B. henselae PCR from biopsy
What are the symptoms of Kawasaki disease?
HOT CREAM
HOT - Fever > 5 days
C - Conjunctivitis R - Rash E - Erythema of the hands and feet A - Adenopathy M - MM involvement (strawberry tongue)
Other findings:
- elevated ESR
- elevated PLT
- normocytic anemia
- sterile pyuria
- abnormal lipid profile
- Echo - need to do to rule out coronary aneurysms
What is the most common neoplasm of the neck based on age?
PRESCHOOL AGE Neuroblastoma Non-Hodgkin's lymphoma Rhabdomyosarcoma Hodgkin's lymphoma
SCHOOL AGE Lymphoma Hogdkin's/Non-hodgkin's lymphoma Thyroid carcinoma Rhabdomyosarcoma
ADOLESCENT
Hodgkin’s lymphoma
What signs and symptoms of a neck mass make you more concerned about a neoplastic lesion?
Painless
Firm
Fixed
Unilateral ptosis
Nasal obstruction
Otorrhea
